Twin Falls Transitional Care of Cascadia

Inspectors wroteBased on observation, interview, policy review, and review of the 2022 FDA Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter and administered oral medication to residents in the dining room. This was true for 1 of 1 resident room observed during the survey process and 1 of 1 resident (Resident #16) observed in the dining room. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on observation, staff interview, and policy review it was determined the facility failed to ensure the facility provided call light access within the resident's reach in 2 facility shower stalls. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wrotebased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified or residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1of 21 residents (Resident #52) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 1 resident (Resident #60) whose record was reviewed for respiratory services. This failure created the potential for the resident to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate and included scheduled and actual hours. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were stored appropriately; this was true for 1 of 21 resident's rooms inspected (Resident #101) and 1 of 1 treatment carts audited. This failure created the potential for adverse effects if residents self-administered medications inappropriately or did not take their medications and created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 20 Residents (Resident #7) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the resident's wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 2 of 20 residents (#32 and #38) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a major mental illness, intellectual disability, or a related condition. This was true for 1 of 8 residents (Resident #58) reviewed for PASARR Level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to resubmit the PASRR level II for those residents with a 30 day exemption when their stay exceeded 30 days. This was true for 3 of 20 residents (#12, #38, and #63) reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician and the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff used opened oxygen supplies after it had fallen on the floor. This was true for 2 of 15 residents (Resident #63 and #41) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue, low oxygen levels and infection.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, record review and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 medications (5.71%) which affected 1 of 6 residents (Resident #38) whose medication administrations were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to ensure medications were properly stored and not expired, and biologicals were labeled when opened. This was true for 1 of 1 medication storage room audited. This failure created the potential for residents to receive expired medications with decreased efficacy and use of expired biologicals.

Inspectors wroteBased on observation, Idaho Food Code review, policy review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure accurate data was entered into a resident's medical record. This was true for 1 of 20 residents (Resident #51) whose medical records were reviewed. This deficient practice placed residents at risk when inaccurate medical data is entered into their medical records.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure proper procedures for cooling leftovers were followed; maintain proper holding food temperatures; and equipment, floors, and dishware were cleaned and/or maintained. This placed all 52 residents residing in the facility who received meals from the kitchen at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on record review, policy review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 1 of 24 residents (Resident #16) whose MDS assessment was reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate MDS assessments.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a new Level 1 Preadmission Screening and Resident Review (PASARR) was completed after a resident had a newly identified mental illness. This was true for 1 of 1 resident (Resident #30) whose PASARR record was reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated screening.

Inspectors wroteBased on record review, policy review, and staff and Resident interview, it was determined the facility failed to implement a restorative nursing program for 2 of 4 Residents (#47 and #308) reviewed for restorative nursing services. This deficient practice created the potential for Residents to experience a decline in strength, range of motion (ROM), and increased pain.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, the facility failed to ensure a fall intervention was implemented. This was true for 1 of 6 residents (Resident #19) reviewed for falls. This deficiency had the potential to cause injury to Resident #19 if he should fall.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure catheter care was provided as ordered. This was true for 2 of 2 residents (#39 and #158) reviewed for urinary catheters. This failed practice created the potential for residents to experience urinary tract infections (UTIs) due to lack of proper care.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure a resident received oxygen therapy per physician's orders. This was true for 1 of 1 resident (Resident #14) reviewed for oxygen therapy. This failure created the potential for Resident #14 to experience hyperoxia (cells, tissues, an organs are exposed to an excess supply of oxygen.